Please, wash your hands before eating!

Here is the typical picture of worst slum areas in Jakarta and other big cities in Indonesia: most of the houses made of recycled wooden pallets, plastic or cardboard boxes, or used asbestos; houses usually have only one room and usually packed with five or more people. The environment surrounding the slums is as poor as the inhabitants: lack of proper sewerage system, no electricity, lack of clean water supply, and sanitary facilities.

In Penjaringan subdistrict, one of slum areas in North Jakarta, people lives in better houses. Most of houses are two stories wooden houses with only two rooms of 3m by 3m. The houses are jammed together, side by side and back to back. The houses hug each other.

There are narrow alleys cross the complex. The houses are the wall of the alleys. Since the alleys are so narrow, the sun disappears from view upon entering them. The alleys have 40 cm wide drainage ditches which clogged with plastic bags, plastic bottles, food scraps, and other household waste. And the garbage not only in sewerage system, they are almost everywhere.

Combination of poor environment and wrong perception on healthy behaviors is cause of high mortality rate of children under five years old. According to Indonesian Demographic Survey 2003, diarrhea is the cause of 19% death amongs children under five years old. About 75 of 100,000 children under five years old of die every year in Indonesia because of diarrheal diseases.

Baseline survey on healthy attitude and behavior done by Environmental Services Program funded by USAID in 18 regencies from eight provinces found that diarrhea prevalence of children under three years is 28%. “Actually diarrhea deseases can be prevented through easy healthy or hygiene behaviors such as washing hands before eating,” said Ms. Nona Pooroe Utomo from ESP-USAID in a discussion with media on how to fight diarrhea through access to clean water and proper sanitation, in Jakarta, 18 January 2007.

The Baseline Qualitative Survey objectives are to understand connection between water and behavior of hygiene life; to identify factors that discourage or encourage people to adopt hygiene life behaviors; to understand attitudes, believes, motivations, and perceptions of hygiene life of the people surveyed.

Val Curtis (a senior lecturer in hygiene promotion) and Sandy Cairncross (a professor of environmental health) from London School of Hygiene and Tropical Medicine, in British Medical Journal 5 July 2003 edition and other publications wrote the impact of improved water, sanitation, and hygiene on reducing diarrhoeal diseases.

By improving the quality of water supplies cuts the risk of diarrhea by only about 16% (although it has other benefits) and making water more available reduce the risk by 20%. Installing adequate facilities to dispose of bodily exretions and promoting hygiene, however, are twice as effective. “A recent systematic review of the impact of washing hands with soap show that this specific practice may be almost three times as effective as improving water quality, cutting the risk of diarrhea by 47%,” wrote the two experts.

It is easy to understand for people of developed countries or rich people of developing countries who live in expensive housing complexes that if hand washing is practiced before eating, it will prevent diarrhoeal diseases. But not for people who live in slum areas Penjaringan or other slum areas in developing countries.

According to the ESP-USAID survey most of people (men and women who have children under three years old) believe that diarrhoeal diseases do not relate to cleanly behavior and good sanitation. They said it because of food contamination, climate, or relate to supernatural power. Some believe that it is a sign that their children are growing up. And some of them who believe that diarrhoeal diseases have connection with cleanliness, garbage and flies are the main infected agents.

How do diarrhoeal diseases spread and get into their children? They said they go from garbage to flies, from flies to food eaten by their children. Or it can be from garbage in the dirty playground to the hands of their children or from garbage in dirty environment to hands of their children.

Most of respondents know how to ward off diarrhea diseases with simple step such as fluid and electrolyte replacement (although they do not really know the reasons). They know when to find medical help. But they also believe that herbals and traditional medicine, even tradisional doctors can cure the diseases.

Perception of cleanness

When respondents were showed pictures of clean people in focus group discussions, they chose Dian Sastro, a famous young Indonesian movie actrees, not ordinary people such as them, explained Utomo. Their perception of cleanness is related to clean physical appearances, good morally and mentally.

In their perception, a clean people, such as Dian Sastro, is physically clean, smells good, always changes clothes after taking a bath, that only rich people can have such kind of cleanness. They believe that poor people is not clean people.

They understand there is strong relation between clean houses with their environment. A clean house has to have garbage cans, good ventilations, trees that create beauty and comforts. They associate health with sunlight that penetrates houses. And in their head, clean environment relates to a better garbage management. It is all citizen responsibility to make cleaner environment.

Clean behaviors

The ESP-USAID survey examined three things related to hygiene behaviors, which were washing hands, preparing foods, and exreting of total 7,137 women respondents who have children under three years old. The results showed that most of them do wash their hands but without soap, although it is easy for them to get soap. Only few women said that they wash their hands with soap, especially after taking care of their children faces.

Soap is used when their hands look dirty, feel sticky, or smell bad, e.g. after handling garbage. For them, dirty is associated with visual appearances not with hygiene.

Housewives surveyed have behavior to wash raw food before cooked them. But the way they wash the food, do not use running water, can contaminate the food with bacteries. They do not comfortable using running water because they cannot see the dirt being washed away. If they use running water, they have to use more water that means they have to spend more money on water.

Most of respondents have no access to proper sanitation facilities. They have no toilets or bathrooms in their houses. They prever to use public open air privies near the rivers or small lake, especially for people live in rural and suburban areas or in slum areas. Economic, cognitive and emotional factors are behind of this behavior.

They believe that excreting in open space does not harm the environment. And everybodies has been practicing it since ever, therefore they do not facing a moral sanction. They said using open air privies are more comfortable because of they can see natural sceneries, breath clean air, and everybodies do it.

Other reason is economic, to save money for other things rather than for water or build toilet inside their houses.

Wash hands campaing

In September 2006, Mercy Corps Indonesia and people of Petojo, another slum area in Jakarta, have built four hand-washing stations in their neighborhood, in areas where children play. Like many other urban poor areas in Jakarta, the residents in Petojo do not have proper sanitation facilities.

Ideally in the stations there should always be a bar of soap, a clean towel ready, besides clean water. There are also pictures drawn at the stations to show “the correct way to wash your hands – by rubbing your hands together with soap.”

A “Wash your hands with soap” campaign, a program of Coalition for Healthy Jakarta supported by Shell Indonesia, proved that people can change their behavior. Before the campaign been conducted in Petamburan district, a poor urban area in Central Jakarta where has children mortality rate 30 of 1,000 children in 2003, only 65% have behavior of washing hands with soap. After the campaign, it increased to 96%.

It is possible to encourage people who live in rural, suburban, or slum areas in the big cities to adopt “wash hand before eating” behavior. The problem is where they can get clean water, or quite cheap clean water. If the water used for washing hands is contaminated especially with human excreta (since most of the privies channel excretes directly to rivers), how can we guarantee that germs are not transmitted.

Municipal Water Corporation can only supply 35% of cities residents. Most of residents get their water from traditional wells or rivers. Indonesian government definitely has to improve sanitation facilities, clean water supply, while NGOs help the residents of urban-poor areas to change their improper behavior to reduce death of diarrhea diseases.

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Hi harry. Good article, easy to understand. I learned quite a bit on the situation in the slums of Jakarta. I will be in Jakarta in August for some video work with slum dwellers and the Red Cross. thanks for the info, keep in touch. where are you based?